Can salvage Retzius-sparing robotic-assisted radical prostatectomy improve continence outcomes? A systematic review and meta-analysis study.

PURPOSE: Salvage Radical Prostatectomy is challenging and associated with high rates of incontinence. The novel Retzius-sparing RARP (RS-RARP) approach has shown impressive high immediate and 1-year continence rates (> 90%) when applied as primary treatment. The purpose of this study is to evaluate the impact of salvage Retzius-sparing RARP (sRS-RARP) on continence outcomes in the salvage scenario. MATERIALS AND METHODS: Using PRISMA guidelines, a systematic review and meta-analysis of articles was conducted on Medline through PubMed and on Cochrane through Central Register of Controlled Trials databases. Inclusion and exclusion criteria were used to select 17 retrospective cohort studies published until April 2023 about sRS-RARP and continence. Data were extracted independently by at least two authors. The International Prospective Register of Systematic Reviews (PROSPERO) was registered. Retrospective studies were subjected to a domain-based risk of bias assessment in accordance with the Newcastle-Ottawa quality assessment scale cohort studies (NOS). Prostate cancer patients were chosen from prospective nonrandomized or randomized sRS-RARP or sS-RARP studies that examined continence outcomes. RESULTS: Seventeen studies were included: 14 were retrospectives only and 3 described retrospective comparison cohorts (sRS-RARP vs sS-RARP). All the retrospective studies were of "fair" quality using the NOS. sRS-RARP may increase recovery of urinary continence after surgery compared to sS-RARP [OR 4.36, 95% CI 1.7-11.17; I2 = 46.8%; studies = 4; participants = 87]. CONCLUSIONS: sRS-RARP approach has potential to improve continence outcomes in the salvage setting. sRS-RARP approach has potential to positively impact continence function on patients who underwent salvage surgery.

Laparoscopic partial nephrectomy without clamping the renal pedicle.

INTRODUCTION: Renal cell carcinoma (RCC) accounts for about 2-3% of all malignancies in adults and 90-95% of renal neoplasms. Curative treatment is eminently surgical, the first reports describing the laparoscopic partial nephrectomy (LPN) date from the beginning of the 1990s since then LPN has been consolidated as a safe and reproducible procedure. In order to improve the results of the LPN in relation to the postoperative renal function, while retaining the benefits of minimally invasive surgery, some surgeons began to implement the technique of laparoscopic partial nephrectomy without renal pedicle clamping (LPNWRPC) in selected cases. OBJECTIVE: To compare the perioperative, oncological and functional results of patients submitted to LPN with renal pedicle clamping (LPNRPC) and LPNWRPC in the hospitals linked to our institution. MATERIAL AND METHOD: All patients' charts were submitted to LPN from January 2000 to January 2016. Data were collected and analyzed retrospectively, patients were divided into two groups: LPNRPC (RPC group) and LPNWRPC (WRPC group). RESULTS: Data from 177 patients submitted to LPN for renal neoplasms were collected, 88 patients (49.7%) in the RPC group and 89 (50.3%) in the WRPC group. Surgical margins were positive in 2.56% of patients in the RPC group and 3.70% in the WRPC group. There was no significant difference despite the technique applied. Clavien 3 or 4 postoperative complications occurred in five cases (5.68%) in the RPC group and three cases in the WRPC group (3.7%), with no significant difference between the groups. Patients in the RPC group developed higher levels of creatinine in the postoperative period (creatinine 1.01 ± 0.16 preoperative vs. 1.12 ± 0.18 postoperatively, p = 0.031) and worsened filtration rate (EGFR) (preoperative 79.18 ± 16.28 × 74.43 ± 21.06 post-operative, p = 0.017). DISCUSSION: Our casuistry agrees with the results of previous studies with regard to major bleeding in patients submitted to LPNWRPC when compared to those submitted to LPNWRPC. However, although bleeding and surgical time were higher in the WRPC group, there was no impact on patients' postoperative evolution regarding both the need for transfusion of blood products and serious complications. In the high-complexity tumors, the mean warm ischemia time (WIT) in the RPC group was higher, this was probably responsible for a better response in the WRPC group evolving patients with lower creatinine levels and better postoperative glomerular filtration rates. CONCLUSION: LPNWRPC has been shown to be equally effective, safe, feasible, with low blood transfusion rates and postoperative complications comparable to LPNRPC, and has similar oncological results. Main impact factor in long-term renal dysfunction is WIT, which can be completely eliminated with the use of LPNWRPC.

Biochemical recurrence-free conditional probability after radical prostatectomy: A dynamic prognosis.

OBJECTIVE: To estimate the conditional biochemical recurrence-free probability and to develop a predictive model according to the disease-free interval for men with clinically localized prostate cancer treated with minimally invasive radical prostatectomy. METHODS: The study population consisted of 3576 consecutive patients who underwent laparoscopic radical prostatectomy and 2619 men treated with robotic radical prostatectomy in the past 15 years at Institute Mutualiste Montsouris, Paris, France. Biochemical recurrence was defined as serum prostate-specific antigen ≥0.2 ng/dL. Univariable and multivariable survival analyses were carried out to identify the prognostic factors for overall free-of-biochemical recurrence probability and conditional survival with respect to the years from surgery without recurrence. A detailed nomogram for the static and dynamic prognosis of biochemical recurrence was developed and internally validated. RESULTS: The median follow-up period was 8.49 years (interquartile range 4.01-12.97), and 1148 (19%) patients experienced biochemical recurrence. Significant variables associated with biochemical recurrence in the multivariable model included preoperative prostate-specific antigen, positive surgical margins, extracapsular extension, pathological Gleason ≥4 + 3 and laparoscopic surgery (all P < 0.001). Conditional survival probability decreased with increasing time without biochemical recurrence from surgery. When stratified by prognosis factors, the 5- and 10-year conditional survival improved in all cases, especially in men with worse prognosis factors. The concordance index of the nomogram was 0.705. CONCLUSIONS: Conditional survival provides relevant information on how prognosis evolves over time. The risk of recurrence decreases with increasing number of years without disease. An easy-to-use nomogram for conditional survival estimates can be useful for patient counseling and also to optimize postoperative follow-up strategies.

Comparative Analysis of Partial Gland Ablation and Radical Prostatectomy to Treat Low and Intermediate Risk Prostate Cancer: Oncologic and Functional Outcomes.

PURPOSE: We analyzed the oncologic and functional outcomes of partial gland ablation compared with robot-assisted radical prostatectomy in patients with low and intermediate risk prostate cancer. MATERIALS AND METHODS: A total of 1,883 patients underwent robot-assisted radical prostatectomy and 373 underwent partial gland ablation from July 2009 to September 2015. We selected 1,458 of these participants for analysis, including 1,222 and 236 treated with robot-assisted radical prostatectomy and partial gland ablation, respectively. Patients had a Gleason score of 3 + 3 or 3 + 4, clinical stage T2b or less, prostate specific antigen 15 ng/dl or less, unilateral disease and life expectancy greater than 10 years. Propensity score matching analysis (1:2) was applied in the overall robot-assisted radical prostatectomy sample, which selected 472 patients for comparison. For partial gland ablation 188 men underwent high intensity focused ultrasound and 48 underwent cryotherapy. Oncologic outcomes were analyzed in terms of the need for salvage treatment. Partial gland ablation failure was defined as any positive control biopsy after treatment. Functional outcomes were assessed by validated questionnaires. RESULTS: Matching was successful across the 2 groups, although men treated with partial gland ablation were older (p <0.001). Mean followup in the partial gland ablation group was 38.44 months. Partial gland ablation failure was observed in 68 men (28.8%), including 53 (28.1%) treated with high intensity focused ultrasound and 15 (31.2%) treated with cryotherapy. Partial gland ablation was associated with a higher risk of salvage treatment (HR 6.06, p <0.001). Complications were comparable between the groups (p = 0.06). Robot-assisted radical prostatectomy was associated with less continence recovery and a lower potency rate 3, 6 and 12 months after surgery (p <0.001). CONCLUSIONS: In select patients with organ confined prostate cancer partial gland ablation offered good oncologic control with fewer adverse effects that required additional treatments. Potency and continence appeared to be better preserved after partial gland ablation.

A Safe teaching protocol of LRP (laparoscopic radical prostatectomy).

PURPOSE: The LRP has a steep learning curve to obtain proficiency during which patient safety may be compromised. We present an adapted modular training system which purpose to optimize the learning curve and perform a safe surgery. MATERIALS AND METHODS: A retrospective analysis of the LRP safe learning protocol applied during a fellowship program over eight years (2008-2015). The surgery was divided in 12 steps and 5 levels of difficulty. A maximum time interval was stipulated in 240 minutes. After an adaptation, the fellows had 120 minutes to perform all the corresponding modules to its accumulated skill. The participants gradually and safely pass through the steps and difficulty levels. Surgeries performed by fellows were analyzed as a single group and compared to a prior series performed by tutor. RESULTS: In eight years, 250 LRP were performed (25 per apprentice) during fellowship program and 150 procedures after completion. The baseline characteristics were comparable. Most cases operated were of intermediate risk. Mean operative time was longer in the fellow group when compared to the tutor (150 min). Mean estimated blood loss were similar among the groups. Functional and oncological outcomes were better in the Tutor´s group. No conversion to open surgery was performed. CONCLUSIONS: The LRP safe learning protocol proved to be an effective method to optimize the learning curve and perform safe surgery. However, the tutor's functional and oncological results were better, showing that this is a procedure with a steep learning curve and proficiency demands more than 25 cases.

Biochemical recurrence after radical prostatectomy: what does it mean?

BACKGROUND: Radical prostatectomy (RP) has been used as the main primary treatment for prostate cancer (PCa) for many years with excellent oncologic results. However, approximately 20-40% of those patients has failed to RP and presented biochemical recurrence (BCR). Prostatic specific antigen (PSA) has been the pivotal tool for recurrence diagnosis, but there is no consensus about the best PSA threshold to define BCR until this moment. The natural history of BCR after surgical procedure is highly variable, but it is important to distinguish biochemical and clinical recurrence and to find the correct timing to start multimodal treatment strategy. Also, it is important to understand the role of each clinical and pathological feature of prostate cancer in BCR, progression to metastatic disease and cancer specific mortality (CSM). Review design: A simple review was made in Medline for articles written in English language about biochemical recurrence after radical prostatectomy. OBJECTIVE: To provide an updated assessment of BCR definition, its meaning, PCa natural history after BCR and the weight of each clinical/pathological feature and risk group classifications in BCR, metastatic disease and CSM.

Effect of Prior Focal Therapy on Perioperative, Oncologic and Functional Outcomes of Salvage Robotic Assisted Radical Prostatectomy.

PURPOSE: We assessed the impact of focal therapy on perioperative, oncologic and functional outcomes in men who underwent salvage robotic assisted radical prostatectomy compared to primary robotic assisted radical prostatectomy. MATERIALS AND METHODS: Focal therapy was performed in patients presenting with Gleason score 3 + 3 or 3 + 4, clinical stage cT2a or less, serum prostate specific antigen 15 ng/ml or less, unilateral positive biopsy, maximum length of any positive core less than 10 mm and life expectancy greater than 10 years. Focal therapy was defined as target ablation of the index lesion plus a 1 cm safety margin in the normal ipsilateral prostatic parenchyma. The salvage group included 22 men who underwent salvage prostatectomy after focal therapy failure. The primary group was defined using matched pair 1:2 selection of 44 of 2,750 patients treated with primary prostatectomy. The primary and secondary end points were the between group differences in functional and oncologic outcomes, respectively. RESULTS: Complication rates were comparable (p >0.05). Pad-free probability was comparable between the groups at 1 and 2 years (p = 0.8). Recovery of erectile function was significantly lower after salvage robotic assisted radical prostatectomy (p = 0.008), which also showed a significantly lower probability of cumulative biochemical recurrence-free survival compared to primary robotic assisted radical prostatectomy (56.3% vs 92.4% at 2 years, p = 0.001). Salvage prostatectomy demonstrated a significantly increased risk of biochemical recurrence (HR 4.8, 95% CI 1.67-13.76, p = 0.004). Study limitations included the retrospective nature, the lack of randomization and the short followup. CONCLUSIONS: Salvage robotic assisted radical prostatectomy after focal therapy failure is feasible with acceptable complication rates. However, patients assigned to primary focal therapy should be advised about a poorer prognosis in terms of oncologic control and lower erectile recovery rates in case of a future salvage surgery.

Surgical method influences specimen margins and biochemical recurrence during radical prostatectomy for high-risk prostate cancer: a systematic review and meta-analysis.

PURPOSE: To perform a meta-analysis comparing the rates of positive surgical margins (PSM) and biochemical recurrence (BCR) between open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) in patients with high-risk prostate cancer. METHODS: A systematic review was performed on Pubmed, Embase and Scopus databases in August 2016, according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. References retrieved were evaluated using the Newcastle-Ottawa scale and the Black and Down's tool for quality assessment. RESULTS: Nine retrospective cohorts comparing ORP and RARP were selected and included in the meta-analysis. All studies reported the PSMs. Patients treated with RARP presented less risk of PSMs (risk difference -0.04, p 0.02) than those treated with ORP. Five articles reported hazard ratios for BCR-free survival. Patients treated with RARP had less risk of BCR (HR 0.72, 95% CI 0.58-0.89) than those treated with ORP. Reports for PSM assessment were considered of adequate quality, while the studies retrieved for BCR assessment were considered limited because of the heterogeneity of their results. CONCLUSION: Patients with high-risk prostate cancer treated with RARP have less risk of having PSM and BCR when compared to those treated with ORP. A strong conclusion is precluded due to the observational nature of the studies retrieved for our analysis.

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: bilateral step-by-step technique.

BACKGROUND: Laparoscopic adrenalectomy is the gold standard surgical approach for small benign adrenal tumors [1]. Several surgical approaches were developed in order to overcome the difficulty to access the adrenal glands, located in the upper retroperitoneum space [2-4]. Laparoendoscopic single-site posterior retroperitoneoscopic adrenalectomy (LESS-PRA) is an emerging technique that reduced the multiple trocar-related trauma and improved cosmetic outcomes while minimizing postoperative morbidity [5-8]. The aim of this study was to describe our step-by-step technique for LESS-PRA and to compare our perioperative outcomes with the conventional 3-port lateral retroperitoneoscopic adrenalectomy (LRA). METHODS: A retrospective review was carried out from February 2008 to January 2016 that included 100 patients with adrenal tumors smaller than 4 cm. Study exclusion criteria were defined as tumor size greater than 4 cm, patients older than 80 years, and body mass index (BMI) greater than 40. A total of 20 patients underwent LESS-PRA and 80 patients underwent 3-port lateral retroperitoneoscopic laparoscopic adrenalectomy. Patient's demographic data and perioperative outcomes were compared and statistically analyzed. The cosmetic satisfaction was evaluated with a visual analog scale. RESULTS: Estimated blood loss was higher in LRA (100 vs. 50 ml; p = 0.35). Operative time was longer in LESS-PRA than LRA (100.0 vs. 60 min; p < 0.001). Analgesic time necessary for LRA was longer than LESS-PRA (40 vs. 24 h; p < 0.001). Cosmetic satisfaction score was higher in LESS-PRA (9.5 vs. 8.6; p = 0.03). There were no significant differences in perioperative complications and length of hospital stay. No conversion to conventional laparoscopic or open surgery was necessary. CONCLUSION: LESS-PRA presented comparable functional and perioperative outcomes to LRA for small adrenal tumors. Although LESS-PRA was associated with longer operative time, it provided inferior estimated blood loss, analgesic time, and improved cosmetic satisfaction.

Focal cryotherapy: step by step technique description.

INTRODUCTION AND OBJECTIVE: Focal cryotherapy emerged as an efficient option to treat favorable and localized prostate cancer (PCa). The purpose of this video is to describe the procedure step by step. MATERIALS AND METHODS: We present the case of a 68 year-old man with localized PCa in the anterior aspect of the prostate. RESULTS: The procedure is performed under general anesthesia, with the patient in lithotomy position. Briefly, the equipament utilized includes the cryotherapy console coupled with an ultrasound system, argon and helium gas bottles, cryoprobes, temperature probes and an urethral warming catheter. The procedure starts with a real-time trans-rectal prostate ultrasound, which is used to outline the prostate, the urethra and the rectal wall. The cryoprobes are pretested and placed in to the prostate through the perineum, following a grid template, along with the temperature sensors under ultrasound guidance. A cystoscopy confirms the right positioning of the needles and the urethral warming catheter is installed. Thereafter, the freeze sequence with argon gas is started, achieving extremely low temperatures (-40ºC) to induce tumor cell lysis. Sequentially, the thawing cycle is performed using helium gas. This process is repeated one time. Results among several series showed a biochemical disease-free survival between 71-93% at 9-70 month- follow-up, incontinence rates between 0-3.6% and erectile dysfunction between 0-42% (1-5). CONCLUSIONS: Focal cryotherapy is a feasible procedure to treat anterior PCa that may offer minimal morbidity, allowing good cancer control and better functional outcomes when compared to whole-gland treatment.

Laparoscopic - assisted transpyelic rigid nephroscopy - simple alternative when flexible ureteroscopy is not available.

INTRODUCTION: In special situations such as malrotated or ectopic kidneys and UPJ stenosis treatment of renal lithiasis can be challenging. In these rare cases laparoscopy can be indicated. OBJECTIVE: Describe the Laparoscopic-assisted rigid nephroscopy performed via transpyelic approach and report the feasibility. PATIENTS AND METHODS: We present two cases of caliceal lithiasis. The first is a patient that ESWL and previous percutaneous lithotripsy have failed, with pelvic kidney where laparoscopic dissection of renal pelvis was carried out followed by nephroscopy utilizing the 30 Fr rigid nephroscope to remove the calculus. Ideal angle between the major axis of renal pelvis and the rigid nephroscope to allow success with this technique was 60-90 grades. In the second case, the kidney had a dilated infundibulum. RESULTS: The operative time was 180 minutes for both procedures. No significant blood loss or perioperative complications occurred. The bladder catheter was removed in the postoperative day 1 and Penrose drain on day 2 when patients were discharged. The convalescence was completed after 3 weeks. Patients were stone free without symptons in one year of follow-up. CONCLUSIONS: Laparoscopic-assisted rigid nephroscopy performed via tranpyelic approach can be done safely with proper patient selection and adherence to standard laparoscopic surgical principles. This approach is an alternative in cases where flexible endoscope is not available and when standard procedure is unlikely to produce a stone-free status.

Retzus-sparing robotic-assisted laparoscopic radical prostatectomy: a step-by-step technique description of this first brazilian experience.

INTRODUCTION: Retzus-sparing robotic-assisted radical prostatectomy(RARP) is a newly approach that preserve the Retzus structures and provide better recovery of continence and erectile function. In Brazil, this approach has not yet been pre¬viously reported. OBJECTIVE: Our goal is to describe Step-by-Step the Retzus-sparing RARP surgical technique and report our first Brazilian experience. METHODS: We present a case of a 60-year-old white man with low risk prostate cancer. Surgical materials were four arms Da Vinci robotic platform system, six transperitoneal portals, two prolene wires and Polymer Clips. This surgical tech¬nique was step-by-step described according to Galfano et al. One additional step was added as a modification of Galfano et al. Primary technique description: The closure of the Denovellier fascia. RESULTS: We have operated one patient with this technique. The operative time was 180minutes, console time was135 min, the blood loss was 150ml, none perioperative or postoperative complications was found, hospital stay of 01 day. The anatomopathological classification revealed a pT2aN0M0 specimen with free surgical margins. The patient achieved continence immediately after bladder stent retrieval. Full erection reported after 30 days of surgery. CONCLUSION: Retzus-sparing RARP approach is feasible and reproducible. However, further comparative studies are neces¬sary to demonstrate potential benefits in continence and sexual outcomes over the standard approaches.

Focal Brachytherapy for Localized Prostate Cancer: Midterm Outcomes.

PURPOSE: Focal brachytherapy (F-BT) is a suitable technique for focal therapy in localized prostate cancer. It has the ability to adapt the seed implantation to the volume and location of the tumor. The aim of this study was to assess F-BT oncologic, functional, and toxicity midterm outcomes in men who underwent prostate cancer treatment. METHODS AND MATERIALS: The study included 39 men with low- to intermediate-risk prostate cancer treated with F-BT between 2010 and 2015. The dose prescription was 145 Gy. Failure was defined as the presence of any residual prostate cancer in the treated area. The primary and secondary endpoints were the F-BT oncologic and functional outcomes, respectively. A 2-sided P value < .05 indicated statistical significance. RESULTS: The mean follow-up time was 65 months (range, 43-104 months). After 24 months, 34 patients underwent control biopsies and 5 patients refused. The biopsies were negative in 27 cases (79%) and positive in 7 cases (21%), all outside the volume treated. Biochemical relapse-free survival at 5 years, disease-free survival, and overall survival were 96.8% ± 0.032%, 79.5% ± 0.076%, and 100%, respectively. The mean International Prostate Symptom Score at 2 months was significantly higher than initially (P = .0003), with no significant difference later. No late urinary, sexual, or rectal toxicity was observed. Salvage treatment was possible with good tolerance at 3.4 years of follow-up. Limitations of this study include the retrospective nature and lack of randomization. CONCLUSIONS: F-BT is a safe and effective treatment for selected patients presenting with low- or intermediate-risk localized prostate cancer.

Chorioallantoic urothelial tumor avatar. A clinical tool for phenotype-based therapy.

In the muscle invasive bladder cancer (MIBC) standard of care treatment only patients presenting a major pathological tumor response are more likely to show the established modest 5% absolute survival benefit at 5 years after cisplatin-based neoadjuvant chemotherapy (NAC). To overcome the drawbacks of a blind NAC (i.e. late cystectomy with unnecessary NAC adverse events) with potential to survival improvements, preclinical models of urothelial carcinoma have arisen in this generation as a way to pre-determine drug resistance even before therapy is targeted. The implantation of tumor specimens in the chorioallantoic membrane (MCA) of the chicken embryo results in a high-efficiency graft, thus allowing large-scale studies of patient-derived "tumor avatar". This article discusses a novel approach that exploits cancer multidrug resistance to provide personalized phenotype-based therapy utilizing the MIBC NAC dilemma.

Should aspirin be suspended prior to robot-assisted radical prostatectomy? A systematic review and meta-analysis.

BACKGROUND: Low-dose aspirin use has been correlated with an increased risk of bleeding and overall complications in surgical and invasive diagnostic procedures. In this review, our aim was to analyze the current literature on whether robot-assisted radical prostatectomy (RARP) is feasible and safe in patients taking low-dose aspirin perioperatively. METHODS: A systematic review was performed identifying a total of 767 studies, published between January 2000 and September 2017, with five of these studies meeting the inclusion criteria for the meta-analysis, totalizing 1481 patients underwent RARP. Patients were divided into two groups: taking aspirin (group A) and those not taking aspirin (group B) perioperatively. RESULTS: There were no significant differences between groups in the overall [group A 10.7% versus group B 15.7%, risk ratio (RR) 0.83; p = 0.45; I 2 = 0%] or major complication rates (group A 1% versus group B 3%, RR 0.98; p = 0.98; I² = 0%), rate of cardiovascular events (group A 1.4% and group B 0.5%, RR 2.06; p = 0.24; I 2 = 9%), blood loss (group A 278 ml versus group B 307 ml, SMD -0.12; p = 0.91; I 2 = 96%), or hospital length of stay [group A 4 days (3-5) and group B 4 days (3-4), SMD -0.09; p = 0.52; I² = 0%]. There was a slightly higher blood-transfusion rate in group A (2.6%) versus group B (1.6%) (RR, 5.05; p = 0.04; I 2 = 0%). CONCLUSION: Continued aspirin use in the perioperative period does not correlate with an increase in surgical morbidity, blood loss, or hospital length of stay. There was a slightly higher blood-transfusion rate in patients taking low-dose aspirin (group A) perioperatively.

Pure Retroperitoneal Optical Access Trocar for Lumbar Diseases in Adults: A Step-by-Step Technique.

PURPOSES: The primary end point of this study was to describe step by step the technique of the pure retroperitoneal optical access trocar (PROAT) in adults. The secondary end point was to access between-group differences in perioperative outcomes. MATERIALS AND METHODS: Forty-five patients underwent retroperitoneoscopic surgery using the PROAT technique to enter the retroperitoneal space (PROAT group). Thirty-nine patients underwent retroperitoneoscopic surgery using the conventional open-Hasson technique with manufactured Hasson-trocar and space-maker balloon to enter and create the retroperitoneal space (conventional group). PROAT technique was described. Data were prospectively collected and analyzed. RESULTS: Mean time for first-entry trocar insertion was lower in the PROAT group (9.76±3.17 vs. 23±7.2 s; P<0.001). Mean time to develop the retroperitoneal space until all-trocar placement was higher in the PROAT group (12.7±3.3 vs. 6.4±2.2 min; P<0.001). Carbon dioxide gas leakage was not observed. CONCLUSIONS: The PROAT technique is feasible and safe. This approach can potentially avoid carbon dioxide leakage when manufactured Hasson trocars are not available and allow a reduced-cost procedure.

Oncological and functional outcomes of elderly men treated with HIFU vs. minimally invasive radical prostatectomy: A propensity score analysis.

AIM: To assess outcomes of whole gland high-intensity focused ultrasound (HIFU) as compared with minimally-invasive radical prostatectomy (MIRP) in elderly patients. MATERIALS & METHODS: Patients aged ≥70 years with, cT1-cT2 disease, biopsy Gleason score (GS) 3 + 3 or 3 + 4 and preoperative PSA ≤10 ng/mL were submitted to either whole-gland HIFU or MIRP. Propensity-score matching analysis was performed to ensure the baseline equivalence of groups. Follow-up visits were routinely performed assessing PSA and urinary function according to the International Continence Score (ICS) and the International Prostatic Symptoms Score (IPSS) questionnaires. Estimated rates of salvage-treatment free survival (SFS) overall-survival (OS), cancer-specific survival (CSS) and metastasis-free survival (MTS) were assessed and compared. RESULTS: Overall, 84 (33.3%) and 168 (66.7%) patients were treated with HIFU and MIRP, respectively. MIRP was associated with a 5-yrs SFS of 93.4% compared to 74.8% for HIFU (p < 0.01). The two groups did not differ in terms of OS and MTS. No cancer-related deaths were registered. Patients treated with HIFU showed better short-term (6-mos) continence outcomes [mean-ICS: 1.7 vs. 4.8; p = 0.005] but higher IPSS mean scores at 12-mos assessment. A comparable rate of patients experiencing post-treatment Clavien-Dindo grade ≥III complications was observed within the two groups. CONCLUSIONS: Whole-gland HIFU is a feasible treatment in elderly men with low-to intermediate-risk PCa and could be considered for patients either unfit for surgery, or willing a non-invasive treatment with a low morbidity burden, although a non-negligible risk of requiring subsequent treatment for recurrence should be expected.

Focal brachytherapy for localized prostate cancer: Urinary toxicity depends on tumor location.

PURPOSE: To evaluate whether patients with prostate cancer have worse functional urinary recovery with focal brachytherapy (FBT) at the base versus the apex of the prostate. METHODS AND MATERIALS: The functional outcomes of patients treated with FBT at the base of the prostate were compared with those of patients treated with FBT at the apex. Urinary symptoms, continence, and erectile dysfunction were measured using the International Prostate Symptom Score (IPSS), International Continence Score (ICS), and International Index of Erectile Function (IIEF-5) questionnaires, respectively, at baseline and at 6, 12, and 24 months after treatment. RESULTS: Twenty-eight and 13 patients were treated with FBT at the apex and the base, respectively, of the prostate. A significant difference between groups was found in the IPSS score at 6 months (mean IPSS: apex 6.4 ± 4.7, base 10.6 ± 5.7; p = 0.02), but not at baseline or at 12 and 24 months after treatment. On multivariate analysis, only FBT at the base of the prostate remained an independent predictor of worsening urinary symptoms (odds ratio, 5.8; p = 0.04). CONCLUSIONS: At 6 months after FBT, significantly less urinary toxicity was found in patients who underwent FBT at the apex versus the base of the prostate. Continence and sexual side effects were minimal in all patients.

The Role of Robot-Assisted Radical Prostatectomy in High-Risk Prostate Cancer.

Prostate cancer (PCa) is stratified into different risk categories based on the patient's prognosis. High-risk disease was formerly characterized by an increased risk of metastasis and lethality, requiring complex treatments. Surgery was recently highlighted to have a pivotal role for the treatment of such cases, even as monotherapy. In the past, open radical prostatectomy was performed for most patients with high-risk PCa; however, robot-assisted radical prostatectomy (RARP) emerged as a reasonable option because it provided optimal outcomes for low- and intermediate-risk PCa. Robust studies are lacking to properly assess the role of RARP for high-risk PCa. We summarize this knowledge and present a literature review on the perioperative recovery and functional and oncologic outcomes of RARP for the treatment of patients with high-risk PCa.